The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CAMBRIDGE HOSPITAL LLC 7601 FANNIN HOUSTON, TX Feb. 20, 2014
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: A2408
Based on interview and record review the hospital failed to ensure 1 of 25 patients reviewed received a timely medical screen examination. (Patient ID# 1)

(A Medical Screen Examination was not performed at Cambridge Hospital by a qualified medical professional. A Medical Screen was not done until the patient arrived at another hospital)

Findings include:


Interview 2/19/14 at 10 a.m. with the intake nurse (ID# 54) revealed the parents of patient ID# 1 recently presented to the hospital with their daughter. The Nurse stated that he performed a triage assessment and the patient was found to be having behavioral problems at school and the nurse deemed the patient was not a threat to herself. The patient's insurance was noted to be out of network (Medicaid) so he called another psychiatric hospital (Hospital ID# 67) and found that the other hospital was in-network for this patient. Cambridge Hospital instructed the patient and family members to go to hospital ID# 67.

The Nurse acknowledged that patient ID# 1 did not see a physician to receive a Medical Screen Examination at Cambridge Hospital. The nurse explained that he did not have a chart or medical record for patient ID# 1.

The Director of Nursing (ID# 50) acknowledged 2/19/14 at 3 p.m. that the Registered Nurses in the intake area are not qualified to perform Medical Screening Examinations.

Record review of a policy titled "Emergency Assessment Process / Medical Screening" dated 3/1/13 stated "Procedure: Walk in patients shall be treated as follows:

1.)
b) Walk in patients shall be medically screened by a qualified medical professional (registered nurse or MD) within 15 minutes of presenting for care.
c) The designated RN is to complete the Initial Medical Screen

Interview 2/20/14 at 1:45 p.m. with the Director of Nursing (ID# 66) at Hospital ID# 67 revealed patient ID# 1 arrived 2/11/14 at their hospital very aggressive, trying to elope and hit people. The patient arrived with her parents. The patient's parents said they were sent to Hospital ID# 67 from Cambridge Hospital. The patient received a Medical Screen Examination upon arriving at Hospital ID# 67. The Director of Nursing at Hospital ID# 67 stated that no paperwork was sent from Cambridge Hospital for patient ID# 1. The Director of Nursing at hospital ID# 67 further stated they had to obtain an emergency detention order and place the patient on one to one monitoring. The patient was subsequently admitted to hospital ID# 67.
VIOLATION: HOSPITAL MUST MAINTAIN RECORDS Tag No: A2403
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview and record review the hospital failed to maintain a record of patient
ID# 1 presenting to Cambridge hospital on [DATE]. (Patient ID# 1)

Findings include:

Interview 2/19/14 at 10 a.m. with intake nurse (ID# 54) revealed the parents of patient
ID# 1 recently presented to the hospital with their daughter. The Nurse stated that he performed a triage assessment and the patient was found to be having behavioral problems at school and the nurse deemed the patient was not a threat to herself. The patient's insurance was noted to be out of network so he called another psychiatric (Hospital ID# 67) and found the other hospital was in-network for this patient. The Nurse acknowledged that patient ID# 1 was not written in the Admission log book of patients presenting to Cambridge Hospital. The nurse explained that he did not have a chart, medical screening examination by a physician or memorandum of transfer form for patient ID# 1's visit to Cambridge Hospital.

Record review of a policy titled "Emergency Assessment Process / Medical Screening" dated 3/1/13 stated "Procedure: Walk in patients shall be treated as follows:

1.)
a) Walk in patients presenting for care shall be recorded into the admission log in book
b) Walk in patients shall be medically screened by a qualified medical professional (registered nurse or MD) within 15 minutes of presenting for care.
c) The designated RN is to complete the Initial Medical Screen

2.) Following medical screening, if the patient shall be transferred to the appropriate medical facility by Memorandum of Transfer, an RN shall assess the need for the patient to be transferred by ambulance or other transport.

b.) To be transferred, the patient / legal representative must request the transfer via Informed Consent for Transfer Form

Record review of the Medical Staff Rules and Regulations on page 3 the following was noted: "Patient transfers: Any patient transfer to another facility must be initiated by the attending psychiatrist or their designee and stated in writing in the physician orders prior to transfer ..."

Interview 2/19/14 at 2:45 p.m. with staff member ID# 55 revealed she was a receptionist at the hospital and assists with paperwork for admissions. The receptionist stated that when patient ID# 1 presented to the hospital her guardians initially presented a United Health care card. The receptionist began completing the consent forms for admission but later found out that the United Health insurance had lapsed. The hospital determined that the patient had Medicaid insurance. The patient / family were instructed to go to another Hospital (Hospital ID #67). The receptionist stated that the patient's medical record and consent forms must have been shredded once the patient left Cambridge Hospital.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on interview and record review the hospital failed to maintain a central log on each individual who comes to the emergency department or Intake area. Patient ID# 1 presented to the hospital 2/11/14 and the patient was not entered on the log.

Findings include:

Record review of a policy titled "Emergency Assessment Process / Medical Screening" dated 3/1/13 stated "Procedure: Walk in patients shall be treated as follows:
1.)
a) "Walk in patients presenting for care shall be recorded into the admission log in book"

Interview 2/19/14 at 10 a.m. with intake nurse (ID# 54) revealed: The Nurse stated that the parents of patient ID# 1 recently presented with their daughter at the hospital. The Nurse stated that he performed a triage assessment and the patient was found to be having behavioral problems at school and the nurse deemed the patient was not a threat to herself. The patient's insurance was noted to be out of network (Medicaid) so he called another hospital (ID# 67) and found that the other hospital was in-network for this patient. The patient's parents were directed to take their daughter to the other hospital.

The Nurse further acknowledged that patient ID# 1 was not written in the Admission log book of patients presenting to Cambridge Hospital.

Record review of the "Admission Log Book" from the intake area revealed: Logs were completed on February 13th, 14th, 17th, and 18th. No other logs were available for previous dates or months. Patient ID# 1 was not noted in the admission log books.

Interview 2/19/14 at 10:30 a.m. with the Director of Nursing (ID# 50) revealed that she could only locate February 13th, 14th, 17th, and 18th in the Admission Log Book. The Nursing Director was unable to locate any other dates in the Admission Log Book. The Nursing Director stated the nursing staff is responsible for keeping the Admission Log book up to date.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on interview and record review the hospital failed to ensure 1 of 25 patients reviewed received a Medical Screening examination upon presenting to the hospital for treatment.
(Patient ID# 1)

Findings include:

Record review of a policy titled "Emergency Assessment Process / Medical Screening" dated 3/1/13 stated "Procedure: Walk in patients shall be treated as follows:

1.)
a) Walk in patients presenting for care shall be recorded into the admission log in book
b) Walk in patients shall be medically screened by a qualified medical professional (registered nurse or MD) within 15 minutes of presenting for care.
c) The designated RN is to complete the Initial Medical Screen

2.) Following medical screening, if the patient shall be transferred to the appropriate medical facility by Memorandum of Transfer, an RN shall assess the need for the patient to be transferred by ambulance or other transport.

Record review of the Medical Staff Rules and Regulations on page 3 revealed the following: "Patient transfers: Any patient transfer to another facility must be initiated by the attending psychiatrist or their designee and stated in writing in the physician orders prior to transfer ... "

Interview 2/19/14 at 10 a.m. with intake nurse ID# 54 at Cambridge Hospital revealed: The Nurse stated that the parents of patient ID# 1 recently presented with their daughter to the hospital. The Nurse stated that he performed a triage assessment. The patient's insurance was noted to be out of network so he called another hospital (ID# 67) and found that the other hospital was in-network for this patient. The nurse stated that he gave the parents directions to get to hospital ID# 67. The Nurse acknowledged that patient ID# 1 did not see a physician to receive a Medical Screen Examination at Cambridge Hospital.

The Director of Nursing (ID# 50) acknowledged 2/19/14 at 3 p.m. that the Registered Nurses in the intake area are not qualified to perform Medical Screening Examinations.

Interview 2/20/14 at 1:45 p.m. with the Director of Nursing (ID# 66) at Hospital ID# 67 revealed patient ID# 1 arrived 2/11/14 at their hospital very aggressive, trying to elope and hit people. The patient arrived with her parents. The patient's parents said they were sent to Hospital ID# 67 from Cambridge Hospital. No paperwork was sent from Cambridge Hospital for patient ID# 1. The Nursing Director stated that Hospital ID# 67 had to obtain an emergency detention order and place the patient on one to one monitoring. The patient was subsequently admitted to the hospital.

Record review of a pre-admission exam by a physician at Hospital ID# 67 stated "Problem: Psychotic symptoms, physical aggression or violence toward others, impaired social performance. I certify that the patient meets the medical / psychiatric necessity criteria for admission to inpatient care ...Per intake staff: Patient is a [AGE] year old with moderate mental retardation, brought in by her biological mother and a caregiver. She was reported to be having increased aggression and assault on the peers at the personal care home where she lives. Patient was also reported to be eloping from the house, creating danger to herself and others ...admitted to hospital due to psychosis ... "